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STATE OF CALIFORNIA* WATER RESOURCES CONTROL BOARD 5E'moi , FORM AA': UNDERGROUND STORAGE TANK PROGRAM io SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IvrS CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 1 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W C.V FACILITY/SITE NAME �J CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓13wardTaa ❑ PNRNfflSHW ❑ STATEAGENCY ❑ TDN LOCAL AGENCY ❑ FEGEM.AGENCY GJ'IFIGIY10JAl ❑ CWNttAGENC! CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREACODE CA gsdvs aog - v6 - as8 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 SSOR ✓Box if INDIAN EPA ID p RESERVATION arIf of TANK's ❑ 1 GAS STATION ❑ 3 FARM OTHER TRUST LANDS ❑ 1 V n e AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE Lh4' u/ C'aorfYJ NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE Gi A0 -e- ! r I , !. IL PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME > CARE OF ADDRESS INFORMATION l PSC9 n MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑� C�ARPORATION 11 LOCAL-AGENCY 11FEDERAL-AGENCY cp ENNDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Sc .rLe as andde // r/ MAILING or STREET ADDRESS ,! "le 11 PARTNERSHIP 11 STATE-AGENCY ❑ Box PORAT[ON ❑ LOCAL-AGENCY ❑ FEDERAL-AG NCY INDIVIOUAI ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ur II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY S FACILITY ID N R of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE N WITH AREA CODE o E ! PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT p SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED ,93 YES NO 1/110%y CHECK p PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M I BY: c v�-- \\ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)ORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. 1 FORM A(3-2-138) M R ``J DATA PROCESSING COPY